Labarca, Gonzalo

Abstract Rationale Endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive method used to diagnose suspected mediastinal lymph nodes or masses. However, the accuracy of the diagnosis in patients with suspected lymphoma is unclear. Objectives To evaluate the diagnostic yield of EBUS-TBNA in patients with suspected lymphoma. Methods A literature search including EMBASE, MEDLINE, Cochrane Library, and Google Scholar was performed by two reviewers. Included articles were evaluated using the QUADAS-2 tool and meta-analysis with a binary method model to compare the sensitivity, specificity, and summary receiver operating characteristic curve in patients with suspected lymphoma. Results Fourteen studies (425 participants) were pooled in the analysis. EBUS-TBNA reported an overall sensitivity of 66.2% (confidence interval [CI], 55–75.8%; I 2 = 76.2%) and specificity of 99.3% (CI, 98.2–99.7%; I 2 = 40%). For a new diagnosis of lymphoma, 13 studies including 243 participants reported sensitivity of 67.1% (CI, 54.2–77.9%; I 2 = 66.8%) and specificity of 99.6% (CI, 99.1–99.8%; I 2 = 0%). For recurrence of lymphoma, 11 studies including 166 participants reported sensitivity of 77.8% (CI, 68.1–85.2%; I 2 = 20.2%) and specificity of 99.5% (CI, 98.9–99.8%; I 2 = 0%). In the recurrence group, we found the use of rapid onsite examination, sample size, and flow cytometry increased the sensitivity of EBUS-TBNA, albeit a potential source of heterogeneity. Conclusions EBUS-TBNA has fair sensitivity for identifying a new diagnosis of lymphoma and fair to good sensitivity for identifying recurrence. Trial Registry PROSPERO CRD42018102773 https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=102773.

Background: Endobronchial ultrasound–guided transbronchial needle aspiration (EBUS-TBNA) is considered to be the initial diagnostic modality for most patients with lung cancer. However, the optimal technique for maximizing yield continues to vary in the real-world setting. Objectives: To evaluate the diagnostic yield of EBUS-TBNA with capillary sampling compared with complete stylet removal for molecular testing. Methods: Retrospective study, data from patients between January to May 2017 with indication of EBUS-TBNA whom ancillary testing, that is, next-generation sequencing, anaplastic lymphoma kinase ( ALK ), and programed death ligand-1 (PD-L1) expression was reviewed. The yield of 2 techniques, stylet retracted halfway (group 1) versus complete retraction (group 2), was compared. Results: A total of 24/27 (88.88%) samples were adequate for next-generation sequencing analysis in group 1 and 21/23 (91.30%) in group 2. For other molecular analyses, 24/27 (88.88%) samples in group 1 and 20/23 (86.95%) samples in group 2 were adequate for ALK analysis. 23/27 (85.18%) samples for group 1 and 20/23 (86.95%) samples for group 2 were adequate for PD-L1 analysis. Positive expression of PD-L1>50% was achieved in 9/23 (39.13%) of group 1 and 5/20 (25%) of group 2. There was no statistical difference in the yield between the 2 groups. Conclusion: EBUS-TBNA using either capillary sampling or complete stylet removal are effective and has a high proportion of satisfactory results for ancillary testing.

AbstractBronchoscopic lung volume reduction (BLVR) is a minimally invasive procedure for patients with symptomatic severe emphysema who may not be candidates for surgical lung volume reduction. BLVR has been shown to improve both functional and clinical outcomes with a relatively low risk of severe complications. Any potential candidate to BLVR should be on optimal pharmacological and nonpharmacological treatment. Radiographic and pulmonary function testing provide key data to help identify potential BLVR candidates. A variety of BLVR techniques have been published with different associated benefits and risks. Current strategies include either blocking procedures such as endobronchial valves and intrabronchial valves or nonblocking procedures such as endobronchial coils and bronchoscopic thermal vapor ablation. The aim of this review is to describe current options of BLVR including their efficacy and safety based on available data.

Abstract Rationale Endobronchial ultrasound and transbronchial needle aspiration (EBUS-TBNA) are commonly used for the diagnosis and mediastinal staging of lung cancer. Molecular markers are becoming increasingly important in patients with lung cancer to define targetable mutations suitable for personalized therapy, such as epidermal growth factor receptor (EGFR), anaplastic lymphoma kinase (ALK), reactive oxygen species proto-oncogene (ROS1), and programmed death-ligand 1 (PD-L1). Objectives To evaluate the adequacy of EBUS-TBNA–derived tissue for molecular analysis. Methods We searched the MEDLINE, LILACS, www.clinicaltrials.gov, and Epistemonikos databases through January 2018. Data Extraction Two independent reviewers performed the data search, quality assessment, and data extraction. We included both prospective and retrospective studies; risk of bias was evaluated using the ROBINS-I tool. The primary outcome was the proportion of adequate samples obtained by EBUS-TBNA for molecular analysis. Data were pooled by using a binary random effects model. Finally, evidence was rated by using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Results A total of 33 studies including 2,698 participants were analyzed. In 28 studies that evaluated EBUS-TBNA for the identification of EGFR mutations, the pooled probability of obtaining a sufficient sample was 94.5% (95% confidence interval CI], 93.2–96.4%). For identification of ALK mutations, the pooled probability was 94.9% (95% CI, 89.4–98.8%). Finally, the prevalence of EGFR mutation was 15.8% (95% CI, 12.1–19.4%), and the prevalence of ALK mutation was 2.77% (95% CI, 1.0–4.8%). Data for ROS1 and PD-L1 mutations were not suitable for meta-analysis. Conclusions EBUS-TBNA has a high yield for molecular analysis of both EGFR and ALK mutations. However, the suitability of TBNA samples for next-generation sequencing is uncertain and should be explored in further studies. Clinical trial registered with PROSPERO (CRD42017080008).

Hydrocephalus is an uncommon presentation of neurosarcoidosis. We discuss the case of a 67‐year‐old woman with a prior diagnosis of hypothyroidism, systemic hypertension, and lung sarcoidosis who presented with a 1‐month history of progressive impairment of consciousness leading to prostration and loss of sphincter control. At admission, patient was febrile with altered speech and without focalization. Laboratory results showed leucocytosis and mild anaemia. Cerebrospinal fluid (CSF) analysis was characterized by mild elevated protein level, increased cell count, normal glucose and adenosine deaminase (ADA), negative cytology, and no bacterial isolations. Electroencephalogram showed toxic‐metabolic encephalopathy. Computed tomography (CT) of the brain revealed hydrocephalus without structural damage, and magnetic resonance imaging of the brain demonstrated non‐specific diffuse meningeal enhancement and periventricular changes supporting normal pressure hydrocephalus. Chest X‐ray showed mediastinal adenopathy and parenchymatous lesions, consistent with stage II lung sarcoidosis. A ventriculoperitoneal shunt was installed, and the patient experienced rapid improvement in her symptoms.